Insurance - Articles

We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

Question:
We have been receiving several DDS referrals to our massage therapists who do intra-oral work. The only problem is that the referral from the DDS lists code R51 for headaches as the only DX code. Since most plans don't cover massage therapy for headaches alone, are there any codes that can distinguish the headaches as ...

Question:
I am a certified DOT medical examiner and have applied to get my CLIA lab (waiver) for urinalysis, finger prick blood tests for A1c, cholesterol and glucose. I realize I cannot diagnose patients with these tests, but I am using them to make decisions in the DOT process and with ...

Pelvic floor dysfunction is often the underlying cause of conditions such as pelvic pain; urinary or bowel dysfunction; and/or sexual symptoms. Treatment generally begins with an evaluation and testing (e.g, EMG) followed by a variety of services (e.g., biofeedback, manipulation, pelvic floor electrical stimulation), depending on the findings.
Coverage by payers ...

We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical information, but usually rely on patients for information on...

Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...

It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):
A state plan must provide ...

On May 11, 2018, the Department of Veterans Affairs (VA) released its final rule on the "Authority of VA Health Care Providers to Practice Telehealth." Effective June 11, 2018, VA providers will be able to provide telehealth services across state lines. This move will make it easier for veterans to obtain ...

Bundled payment models continue to attract interest for their potential benefits over traditional fee-for-service payment models. With bundled payments, also known as episode-based payments or packaged pricing, a group of providers is reimbursed based on a contracted price to cover all of the care and services related to a particular ...

Anthems original plan was to take a 50% reduction when providers reported claims using modifier 25, it was then lowered to a 25% reduction and has now been fully rescinded, to the relief of providers. The policy was to go into effect March 1, 2018, however, due to strong opposition from ...

High Deductible Health Plans (HDHPs) are recent and growing trend in healthcare that is probably here to stay, regardless of the future changes to the national healthcare system or federal regulations.....

2017

As the opportunities for providers outside the VA system expand in order to meet demand, you may be interested in offering services to veterans and the VA, if you are not already. With overwhelming bipartisan support, the opportunities are not likely to abate, but are those opportunities worth it for ...

If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely serious. I don't need to tell you this.
I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate ...

Do you need help with cases and calculating groups of Risk Scores?
Per customers request, Find-A-Code now offers BULK entry for calculating for Risk Scores. The HCC Risk tool offers two options for calculating risk scores, we now offer a BULK calculation for cases or the calculation for a single enrollee.
To use the BULK calculation for cases
Create ...

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients.

2016

Are you one of those busy physicians who pay just a cursory glance at monthly collections? Then you should be prepared to lose revenue every single day like this obgyn practice in southeast Georgia. It is essential for medical practices to track financial performance metrics, as every dollar that...

Workers’ Compensation is for work related illness or injuries on the job. The employer pays for insurance which covers medical costs incurred, and replaces lost wages. Fees are based on a specific fee schedule that varies by state.
There are three possible scenarios regarding workers’ compensation: the patient is covered by ...

If your dental office isn’t billing medical insurance for certain procedures, you’re missing out on an important way of serving your patients and expanding your practice. Currently, only about 64% of Americans are covered by a dental insurance plan. But the Affordable Care Act requires nearly 100% of Americans to be covered ...

As the healthcare industry undergoes dramatic transformation, group practices are facing a lot of turbulence to their financial structuring. Moving away from fee-for-service business models to value-based reimbursement setup is a daunting endeavor, but, that’s where the industry is heading...

2015

During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies. It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the...

2014

Do you routinely balance bill your patients? Do you send the statement as soon as you hear from insurance or do you wait until the end of the month?
Balance billing your patients is essential for several reasons. First, it increases your revenue. It may not seem like a lot of money, but the...

Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure?
In many cases outpatient procedures and...

Do you feel like you are fighting a losing battle? Are you watching your account receivables going up and your collections going down? Is your cash flow suffering? What is a practice to do?
One of the most effective ways to keep your cash flowing is by checking your patient’s...

Charity programs that help patients pay for the rising cost-sharing obligations of needed drugs may run afoul of anti-kickback rules when the charity’s scope is so narrow that it guides the patient toward specific drugs for treatment or providers, the HHS Office of Inspector General said last...

One provision of the Affordable Care Act (ACA) that can work to your practice’s advantage is Section 1104, which gives you the right to insist on electronic funds transfer (EFT) as your method of payment.
As of Jan. 1, 2014, you are entitled to EFT payments upon your request under standards...

2013

Health insurance policies issued as part of the state and federal health insurance exchanges under the Affordable Care Act (ACA) will take effect Jan. 1, 2014. That means that, starting on that date, patients may present to your office for insurance coverage under the plans. Here are the things you...

Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims. Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons. I even have a little dance that I do! Why not? We need to get...